Robust scientific research has demonstrated that diabetes disproportionately affects minorities in the United States. Nationwide, among people aged 20 years or older, diabetes affects 12.6% of non-Hispanic Blacks, 11.8% of Hispanics, and 8.4% of Asian Americans compared to 7.1% of whites. In regard to diabetes care, racial and ethnic disparities have also been documented. For example, African Americans and Latinos have been shown to display poorer glycemic control and receive fewer HbA1c level tests, a measure of blood sugar control, than their white counterparts.
An assessment of diabetes care at the Massachusetts General Hospital revealed two populations (Latinos and Cambodians) that were more likely to be in poor control than their white counterparts. For example, in 2005, Latinos were more likely to be in poor diabetes control (17.5%) compared to English-speaking white patients (9.1%) at the MGH Chelsea Health Care Center which serves the MGH’s largest Latino community.
To address the disparity at the MGH Chelsea facility, the Disparities Solutions Center (DSC) in collaboration with the MGH Chelsea Health Care Center, the Massachusetts General Physicians Organization (MGPO), and the MGH Center for Community Health Improvement, developed a culturally competent and comprehensive diabetes management program for patients with poorly controlled diabetes. The Chelsea Diabetes Management Program (CDMP) aimed at reducing disparities while improving care for all patients. The CDMP is based on a culturally and linguistically competent disease management model and has three main program components:
As of March 2010, approximately 519 patients have participated in the program, which is available to both Spanish (65%) and English (23%) speaking patients. A total of 3,024 coaching sessions were conducted with a mean of five coaching sessions per person. Sixty-three percent of patients received at least three coaching sessions. Preliminary results show a statistically significant mean reduction in HbA1c levels for enrolled patients. The program has also had an impact on diabetes disparities at MGH Chelsea overall. In 2005 when the program started, 17.5% of Latinos with diabetes were in poor control (HbA1c >9) compared to 9.1% of whites - a difference of 8.4 percentage points. As of 2009 that gap reduced to 5.3 percentage points.
Robust scientific research has demonstrated that reduction in morbidity and mortality can be achieved through early detection and treatment, yet many patients are not diagnosed until the disease has advanced. Despite its efficacy and cost-effectiveness for reducing the incidence and mortality of cancer, screening rates can be improved, especially for racial and ethnic minorities.
In 2006, a disparity was identified in colorectal cancer (CRC) screening between Latinos (41%) and whites (58%). To address this disparity, the Chelsea Colorectal Cancer Screening Program was designed as a quality improvement and disparities reduction intervention. The program targets patients who are due for CRC screening and have not received it. As part of program development, forty interviews were conducted with patients to identify specific barriers to care for CRC screening and to assess patients’ knowledge, beliefs, and experiences with colonoscopy screenings (or reasons for not having a screening).
Based on the findings from the patient interviews regarding CRC screenings, a culturally and linguistically tailored colorectal cancer navigator program was implemented in January 2007.
The navigators, who are also outreach workers and interpreters at the health center, were trained to:
A randomized control trial, using an intention-to-treat strategy, was conducted from January to October of 2007. Results showed that patients in the intervention group (receiving navigator services) were more likely to undergo CRC screening than patients receiving usual care services (27% vs. 12% for any CRC screening, p.<0.001; 21% vs. 10% for colonoscopy completion, p.<0.001 ). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 for those receiving usual care (p=0.04).
Since completion of the randomized control trial, the navigator program has continued to be available to all patients at MGH Chelsea. During 2008 and 2009, 197 patients received a colonoscopy with the assistance of the navigators. In 2010, the program expanded with additional funding from the Trefler Foundation, and an additional part-time navigator was hired, which allowed for increased recruitment efforts and provision of program services.
Recent data show the CRC patient navigation has been very successful:
In 2008, disparities in breast cancer screening were identified between female refugees and immigrants (from Somalia, Bosnia, and the Middle East) and English and Spanish-speaking females at the MGH Chelsea Health Care Center. To address this disparity, a culturally and linguistically-tailored refugee breast cancer screening navigator program was implemented to help patients overcome the personal, cultural, and systemic barriers to mammography.
Funding for this quality improvement and disparities reduction initiative was provided by the Susan G. Komen for the Cure, Massachusetts Affiliate. The Chelsea Komen Breast Cancer Program for Refugees was designed to target patients who were due for a breast cancer screening and had not received screening services. The program utilizes bilingual patient navigators, from the targeted underserved communities (Somali, Bosnian, and Arabian), to educate women about breast cancer screening, identify patients' specific barriers to screening, and develop a plan to overcome barriers. The navigators assist patients by scheduling appointments, translating, and accompanying patients (if needed) to mammography appointments.
The culturally-tailored patient navigator program not only significantly increased the mammography rates in Arabian, Somalian, and Bosnian refugees but also eliminated and reduced disparities that existed between English/Spanish-speaking patients and these most vulnerable female patients - Serbo-Croatian speaking refugee females at the MGH Chelsea Health Care Center.